Documenting skin ulcers: The pressure is on

CMS’ Value-Based Purchasing Initiative considers pressure ulcers to be reasonably
preventable and has included them on its list of so-called “no pay”
conditions. In other words, hospitals won't be paid for the cost of treating pressure
ulcers if they occur during a hospital stay and aren't documented as present on admission.
Of the 11 hospital-acquired conditions selected for nonpayment in 2009, pressure ulcers
may be the most difficult to accurately code and report. In Medicare's MS-DRG payment
methodology, only stage III and IV pressure ulcers (see Table) are considered major complications or comorbidities (MCCs) resulting in a significant
increase in hospital reimbursement when a physician documents them as present on admission.

For example, in a patient with a principal diagnosis of aspiration pneumonia and a
secondary diagnosis of a stage I, stage II, or unstaged pressure ulcer, the MS-DRG
would be 179, complex pneumonia without complications or comorbidities (CCs) or MCCs,
and reimbursement would be $7,015 (all reimbursements are based on a hospital-specific
rate of $5,500). In a patient with a stage III to IV pressure ulcer documented as
present on admission, the MS-DRG would be 177, complex pneumonia with MCC, and reimbursement
would be $10,144.

A stage III or IV pressure ulcer that develops during the hospital stay or that is
not documented by the physician as present on admission will result in a payment reduction
unless another MCC is documented and coded. For example, the patient above with a
stage III or IV pressure ulcer not present at admission would be classified as MS-DRG
179, complex pneumonia without CC/MCC, and reimbursement would be $7,015, the same
as if the pressure ulcer were less severe.

Pressure ulcers noted by wound care nurses or physical therapists and in nursing assessments
are not reportable as MCCs, nor does such documentation establish that they were present
on admission. Reportable diagnoses are limited to those conditions documented by the
provider responsible for establishing the patient's diagnosis. However, when the physician
has documented the presence of a pressure ulcer and its location, the stage of the
ulcer is reportable based on nurse or physical therapist documentation (ICD-9-CM Official
Guidelines for Coding and Reporting, effective Oct. 1, 2008). The ICD-9-CM code representing
the stage of the ulcer determines whether the condition is an MCC.

While stage I or II pressure ulcers are not considered CCs or MCCs and don't impact
MS-DRG reimbursement, they do affect the patient's risk of complication or death and
should be documented by the physician and assigned ICD-9-CM codes by the hospital
coder. If a patient is diagnosed with a stage I or II pressure ulcer on admission
that progresses to stage III or IV during the hospital stay, the coder will report
the highest stage and note that the ulcer was present on admission because the stage
I, II, or unstageable ulcer was diagnosed then. Documentation should clearly indicate
whether the pressure ulcer (at any stage) was present on admission or developed later.

Document cause and related factors

Physician documentation of the specific cause of a skin ulcer is important to accurate
coding. Coders may not assume cause-and-effect relationships between a disease process
and a skin ulceration. When “ulcer” is documented in diabetic patients
without further specification, for example, the coder will need to query the physician
to clarify whether it is a diabetic ulcer or a pressure ulcer. Be sure to make the
connections necessary for accurate reporting. For diabetic ulcers, for example, document
any related diabetic manifestation if applicable

due to diabetic peripheral neuropathy;

due to diabetic peripheral vascular disease; or

due to combined diabetic peripheral vascular disease and atherosclerosis.

Also document other factors related to the skin ulcer. Is there more than one ulcer?
Does the patient have cellulitis? Is the ulcer acutely infected with systemic inflammatory
response syndrome (SIRS with sepsis due to infected wound)? These additional conditions
will establish a higher severity of illness that will help guide treatment and will
also increase the MS-DRG reimbursement.

Document associated procedures

Associated procedures such as debridement are eligible for increased reimbursement.
Excisional debridement involves removal of devitalized tissue with a scalpel (as opposed
to brushing or washing) and may be performed by a physician, physician's assistant,
nurse or therapist in any location. The use of a sharp instrument doesn't always indicate
that an excisional debridement was performed according to coding guidelines. Documentation
of the depth of the debridement is necessary when it extends beyond skin or subcutaneous tissue
(bone, muscle).

When multiple layers are debrided (i.e., skin and subcutaneous tissue, muscle, bone),
only the deepest layer of debridement is reported. If that tissue is not specifically
identified in ICD-9-CM, the procedure is reported as an excision of lesion of that
site (i.e., excision of lesion of soft tissue).

The excisional procedure (although not performed in the OR) will change the MS-DRG
assignment, significantly increasing reimbursement. Document the details of the procedure
carefully; this procedure code is a target of Recovery Audit Contractors who recoup
improper payments made for excisional debridement when the documentation does not
describe the excisional nature of the procedure. “Sharp” debridement
is not a substitute for excisional debridement.

Consider a patient with a principal diagnosis of aspiration pneumonia and a secondary
diagnosis of a stage III to IV pressure ulcer present on admission. If excisional
debridement is performed (ICD-9-CM code 86.22), the procedure is classified as MS-DRG
166, procedures for a patient admitted with a respiratory system principal diagnosis
with MCC. Reimbursement would be $17,972, based on a hospital-specific rate of $5,500,
compared with $10,144 if the debridement was nonexcisional (brushing, washing or snipping
of devitalized tissue).

Deborah Hale, a certified coding specialist, is president of Administrative Consultant
Service, LLC, in Shawnee, Okla. For the past 21 years, she has provided utilization
management, coding, billing and clinical documentation improvement consultation for
hospitals throughout the U.S., including the state of New York's severity-refined
DRG system. Email us your coding questions.

CMS’ hospital-acquired conditions

The following conditions are not considered as MCC/CCs to increase hospital payment
if they aren't present when the admission order for inpatient status is written, according
to the FY09 final rule:

air embolism following procedure;

blood incompatibility;

catheter-associated urinary tract infection;

deep venous thrombosis/pulmonary embolism after hip/knee replacement;

foreign objects left in during surgery;

hospital-acquired trauma;

poor glycemic control;

stage III or IV pressure ulcers;

mediastinitis following coronary artery bypass grafting;

surgical site infection following specific bariatric and orthopedic procedures; and

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.